<!DOCTYPE html>
<html lang="zh">
<head>
	<meta charset="UTF-8" />
	<meta name="viewport" content="width=device-width, initial-scale=1, maximum-scale=1, user-scalable=no">
	<meta http-equiv="X-UA-Compatible" content="ie=edge" />
	<link rel="stylesheet" type="text/css" href="../../css/global/mui.css"/>
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	<title>随访记录</title>
</head>
<body>
	<div  class="mui-input-group font3">
		<div class="mui-table-view-cell">
			<div class="mui-navigate-right">
				随访日期
				<span class="mui-pull-right" id="followDate">请选择</span>
			</div>
		</div>
		<div class="mui-table-view-cell">
			<div class="mui-navigate-right">
				随访形式
				<span class="mui-pull-right" id="formal">请选择</span>
			</div>
		</div>
	</div>
	<input type="hidden" name="visitDate" value="" />
	<input type="hidden" name="visitType" value="" />
	<form class="form2 font3" id="form4">
		<div  class="mui-input-group">
			<input type="hidden" name="loseInfo" value="" />
			<div class="mui-table-view-cell">
				<div class="mui-navigate-right">
					走失原因
	                <span class="mui-pull-right" id="missing">请选择</span>
                </div>
			</div>
		</div>
	</form>
	<form class="form3 font3" id="form5">
		<div  class="mui-input-group">
			<div class="mui-table-view-cell">
				<div class="mui-navigate-right">
					死亡日期
					<span class="mui-pull-right" id="deathTime">请选择</span>
					<input type="hidden" name="dieInfo[d_time]" value="" />
				</div>
			</div>
			<div class="mui-table-view-cell">
				<div class="mui-navigate-right">
					死亡原因
					<span class="mui-pull-right" id="causeDeath">请选择</span>
					<input type="hidden" name="dieInfo[d_why]" value="" />
				</div>
			</div>
			<div class="mui-row Multiselect" id="trunkDisease">
				<div class="mui-col-xs-12">死亡原因<span>躯干疾病</span></div>
				<div class="mui-col-xs-6">
					<div class="mui-input-row mui-radio mui-left">
				  		<label>染病和寄生虫病</label>
				  		<input name="dieInfo[d_why]" value="1" type="radio">
					</div>
				</div>
				<div class="mui-col-xs-6">
					<div class="mui-input-row mui-radio mui-left">
				  		<label>肿瘤</label>
				  		<input name="dieInfo[d_why]" value="2" type="radio">
					</div>
				</div>
				<div class="mui-col-xs-6">
					<div class="mui-input-row mui-radio mui-left">
				  		<label>心脏病</label>
				  		<input name="dieInfo[d_why]" value="3" type="radio">
					</div>
				</div>
				<div class="mui-col-xs-6">
					<div class="mui-input-row mui-radio mui-left">
				  		<label>脑血管病</label>
				  		<input name="dieInfo[d_why]" value="4" type="radio">
					</div>
				</div>
				<div class="mui-col-xs-6">
					<div class="mui-input-row mui-radio mui-left">
				  		<label>呼吸系统疾病</label>
				  		<input name="dieInfo[d_why]" value="5" type="radio">
					</div>
				</div>
				<div class="mui-col-xs-6">
					<div class="mui-input-row mui-radio mui-left">
				  		<label>消化系统疾病</label>
				  		<input name="dieInfo[d_why]" value="6" type="radio">
					</div>
				</div>
				<div class="mui-col-xs-6">
					<div class="mui-input-row mui-radio mui-left">
				  		<label>其他疾病</label>
				  		<input name="dieInfo[d_why]" value="7" type="radio">
					</div>
				</div>
				<div class="mui-col-xs-6">
					<div class="mui-input-row mui-radio mui-left">
				  		<label>不详</label>
				  		<input name="dieInfo[d_why]" value="8" type="radio">
					</div>
				</div>
			</div>	
		</div>
	</form>
	<form class="form1 font3"  id="form">
		<div  class="mui-input-group">
			<input type="hidden"  name="socialInfo[grades]"  value=""/>
			<div class="mui-table-view-cell">
				<div class="mui-navigate-right">
					危险性
					<span class="mui-pull-right" id="danger">请选择</span>
				</div>
			</div>
			<div class="mui-row Multiselect" id="Multiselect66">
				<div class="mui-col-xs-12">目前症状</div>
				<div class="mui-col-xs-6">
					<div class="mui-input-row mui-checkbox mui-left">
				  		<label>幻觉</label>
				  		<input name="riskInfo[hj]" value="1" type="checkbox" data-type="wxmqzz">
					</div>
				</div>
				<div class="mui-col-xs-6">
					<div class="mui-input-row mui-checkbox mui-left">
				  		<label>交流困难</label>
				  		<input name="riskInfo[jl]" value="2" type="checkbox" data-type="wxmqzz">
					</div>
				</div>
				<div class="mui-col-xs-6">
					<div class="mui-input-row mui-checkbox mui-left">
				  		<label>猜忌</label>
				  		<input name="riskInfo[cj]" value="3" type="checkbox" data-type="wxmqzz">
					</div>
				</div>
				<div class="mui-col-xs-6">
					<div class="mui-input-row mui-checkbox mui-left">
				  		<label>喜怒无常</label>
				  		<input name="riskInfo[xn]" value="4" type="checkbox" data-type="wxmqzz">
					</div>
				</div>
				<div class="mui-col-xs-6">
					<div class="mui-input-row mui-checkbox mui-left">
				  		<label>行为怪异</label>
				  		<input name="riskInfo[xw]" value="5" type="checkbox" data-type="wxmqzz">
					</div>
				</div>
				<div class="mui-col-xs-6">
					<div class="mui-input-row mui-checkbox mui-left">
				  		<label>兴奋话多</label>
				  		<input name="riskInfo[xf]" value="6" type="checkbox" data-type="wxmqzz">
					</div>
				</div>
				<div class="mui-col-xs-6">
					<div class="mui-input-row mui-checkbox mui-left">
				  		<label>伤人毁物</label>
				  		<input name="riskInfo[sr]" value="7" type="checkbox" data-type="wxmqzz">
					</div>
				</div>
				<div class="mui-col-xs-6">
					<div class="mui-input-row mui-checkbox mui-left">
				  		<label>悲观厌世</label>
				  		<input name="riskInfo[ys]" value="8" type="checkbox" data-type="wxmqzz">
					</div>
				</div>
				<div class="mui-col-xs-6">
					<div class="mui-input-row mui-checkbox mui-left">
				  		<label>无故外走</label>
				  		<input name="riskInfo[wg]" value="9" type="checkbox" data-type="wxmqzz">
					</div>
				</div>
				<div class="mui-col-xs-6">
					<div class="mui-input-row mui-checkbox mui-left">
				  		<label>自语自笑</label>
				  		<input name="riskInfo[zy]" value="10" type="checkbox" data-type="wxmqzz">
					</div>
				</div>
				<div class="mui-col-xs-6">
					<div class="mui-input-row mui-checkbox mui-left">
				  		<label>孤僻懒散</label>
				  		<input name="riskInfo[gp]" value="11" type="checkbox" data-type="wxmqzz">
					</div>
				</div>
				<div class="mui-col-xs-6">
					<div class="mui-input-row mui-checkbox mui-left writeRemarksClick">
				  		<label>其它（需备注）</label>
				  		<input name="riskInfo[qt]" value="12" type="checkbox" data-type="wxmqzz">
					</div>
				</div>
			</div>
			<div class="mui-input-row writeRemarks writeRemarks0">
				<input type="text" placeholder="请输入备注信息" name="riskInfo[write]" disabled="true">
			</div>
		</div>
		<div  class="mui-input-group font3">
			<input type="hidden"  name="perception"  value="" />
			<div class="mui-table-view-cell">
				<div class="mui-navigate-right">
					自知力
					<span class="mui-pull-right" id="knowledge">请选择</span>
				</div>
			</div>
			<input type="hidden"  name="sleepStatus"  value="" />
			<div class="mui-table-view-cell">
				<div class="mui-navigate-right">
					睡眠状况
					<span class="mui-pull-right excellent">请选择</span>
				</div>
			</div>
			<input type="hidden"  name="dietaryStatus"  value="" />
			<div class="mui-table-view-cell">
				<div class="mui-navigate-right">
					饮食状况
					<span class="mui-pull-right excellent1">请选择</span>
				</div>
			</div>
		</div>
		<div class="mui-input-title font1">
			社会功能情况
		</div>
		<div  class="mui-input-group font3">
			<input type="hidden"  name="socialInfo[shenghuo]"  value="" />
			<div class="mui-table-view-cell">
				<div class="mui-navigate-right">
					个人生活料理
					<span class="mui-pull-right excellent2">请选择</span>
				</div>
			</div>
			<input type="hidden"  name="socialInfo[jiawu]"  value="" />
			<div class="mui-table-view-cell">
				<div class="mui-navigate-right">
					家务劳动
					<span class="mui-pull-right excellent3">请选择</span>
				</div>
			</div>
			<input type="hidden"  name="socialInfo[laodong]"  value="" />
			<div class="mui-table-view-cell">
				<div class="mui-navigate-right">
					生产劳动及工作
					<span class="mui-pull-right excellent4">请选择</span>
				</div>
			</div>
			<input type="hidden"  name="socialInfo[xuexi]"  value="" />
			<div class="mui-table-view-cell">
				<div class="mui-navigate-right">
					学习能力
					<span class="mui-pull-right excellent5">请选择</span>
				</div>
			</div>
			<input type="hidden"  name="socialInfo[jiaowang]"  value="" />
			<div class="mui-table-view-cell">
				<div class="mui-navigate-right">
					社会人际交往
					<span class="mui-pull-right excellent6">请选择</span>
				</div>
			</div>
		</div>
		<div  class="mui-input-group font3">
			<div class="mui-row Multiselect">
				<div class="mui-col-xs-12">目前症状</div>
				<div class="mui-col-xs-9">
					<div class="mui-input-row mui-checkbox mui-left">
				  		<label>轻度滋事</label>
				  		<input name="zhengzhuang" value="1" type="checkbox">
					</div>
				</div>
				<div class="mui-col-xs-3">
					<div class="frequency">
				  		<input type="number" placeholder="0" disabled="true" name="symptomInfo[qingdu]" class="getsymptomInfo">
				  		<span>次</span>
					</div>
				</div>
				<div class="mui-col-xs-9">
					<div class="mui-input-row mui-checkbox mui-left">
				  		<label>肇事</label>
				  		<input name="zhengzhuang" value="2" type="checkbox">
					</div>
				</div>
				<div class="mui-col-xs-3">
					<div class="frequency">
				  		<input type="number" placeholder="0" disabled="true" name="symptomInfo[zhaoshi]" class="getsymptomInfo">
				  		<span>次</span>
					</div>
				</div>
				<div class="mui-col-xs-9">
					<div class="mui-input-row mui-checkbox mui-left">
				  		<label>肇祸</label>
				  		<input name="zhengzhuang" value="3" type="checkbox">
					</div>
				</div>
				<div class="mui-col-xs-3">
					<div class="frequency">
				  		<input type="number" placeholder="0" disabled="true" name="symptomInfo[zhaohuo]" class="getsymptomInfo">
				  		<span>次</span>
					</div>
				</div>
				<div class="mui-col-xs-9">
					<div class="mui-input-row mui-checkbox mui-left">
				  		<label>其他危害行为</label>
				  		<input name="zhengzhuang" value="4" type="checkbox">
					</div>
				</div>
				<div class="mui-col-xs-3">
					<div class="frequency">
				  		<input type="number" placeholder="0" disabled="true" name="symptomInfo[qita]" class="getsymptomInfo">
				  		<span>次</span>
					</div>
				</div>
				<div class="mui-col-xs-9">
					<div class="mui-input-row mui-checkbox mui-left">
				  		<label>自伤</label>
				  		<input name="zhengzhuang" value="5" type="checkbox">
					</div>
				</div>
				<div class="mui-col-xs-3">
					<div class="frequency">
				  		<input type="number" placeholder="0" disabled="true" name="symptomInfo[zishang]" class="getsymptomInfo">
				  		<span>次</span>
					</div>
				</div>
				<div class="mui-col-xs-9">
					<div class="mui-input-row mui-checkbox mui-left">
				  		<label>自杀未遂</label>
				  		<input name="zhengzhuang" value="6" type="checkbox">
					</div>
				</div>
				<div class="mui-col-xs-3">
					<div class="frequency">
				  		<input type="number" placeholder="0" disabled="true" name="symptomInfo[zisha]" class="getsymptomInfo">
				  		<span>次</span>
					</div>
				</div>
				<div class="mui-col-xs-9">
					<div class="mui-input-row mui-checkbox mui-left">
				  		<label>无</label>
				  		<input name="zhengzhuang" value="7" type="checkbox">
					</div>
				</div>
				<!--<div class="mui-col-xs-3">
					<div class="frequency">
				  		<input type="text" placeholder="0" disabled="true" name="symptomInfo[wu]" class="getsymptomInfo">
				  		<span>次</span>
					</div>
				</div>-->
			</div>
		</div>
		<div  class="mui-input-group font3">
			<input type="hidden"  name="isBelock"  value="" />
			<div class="mui-table-view-cell">
				<div class="mui-navigate-right">
					两次随访期间关锁情况
					<span class="mui-pull-right" id="closeLock">请选择</span>
				</div>
			</div>
			<input type="hidden"  name="inHospital"  value="" />
			<div class="mui-table-view-cell">
				<div class="mui-navigate-right">
					两次随访期间住院情况
					<span class="mui-pull-right" id="Hospitalization">请选择</span>
				</div>
			</div>
			<input type="hidden"  name="leaveHosDate"  value="" />
			<div class="mui-table-view-cell leaveTime">
				<div class="mui-navigate-right">
					末次出院时间
					<span class="mui-pull-right" id="leaveTime">请选择</span>
				</div>
			</div>
		</div>
		<div  class="mui-input-group font3">
			<div class="mui-row Multiselect">
				<div class="mui-col-xs-12">实验室检查</div>
				<div class="mui-radio mui-left mui-input-row">
			  		<label>无</label>
					<input name="otherInfo[jiancha]" type="radio" value="0">
				</div>
				<div class="mui-input-row mui-radio mui-left">
			  		<label>有(需备注)</label>
					<input name="otherInfo[jiancha]" type="radio" value="1">
				</div>
			</div>
			<div class="mui-input-row writeRemarks writeRemarks1">
				<input type="text" placeholder="请填备注信息" name="otherInfo[jcDetail]" disabled="true">
			</div>
		</div>
		<div  class="mui-input-group font3">
			<input type="hidden"  name="otherInfo[yilaxing]"  value="" />
			<div class="mui-table-view-cell">
				<div class="mui-navigate-right">
					用药依从性
					<span class="mui-pull-right" id="Medication">请选择</span>
				</div>
			</div>
			<div class="mui-row Multiselect">
				<div class="mui-col-xs-12">药物不良反应</div>
				<div class="mui-radio mui-left mui-input-row">
			  		<label>无</label>
					<input name="otherInfo[fanying]" type="radio" value="0">
				</div>
				<div class="mui-input-row mui-radio mui-left">
			  		<label>有(需备注)</label>
					<input name="otherInfo[fanying]" type="radio" value="1">
				</div>
			</div>
			<div class="mui-input-row writeRemarks writeRemarks2">
				<input type="text" placeholder="请填备注信息"  name="otherInfo[fyDetail]" disabled="true">
			</div>
		</div>
		<div  class="mui-input-group font3">
			<input type="hidden"  name="otherInfo[xiaoguo]"  value="" />
			<div class="mui-table-view-cell">
				<div class="mui-navigate-right">
					治疗效果
					<span class="mui-pull-right" id="treatment">请选择</span>
				</div>
			</div>
			<div class="mui-row Multiselect Multiselect2">
				<div class="mui-col-xs-12">是否转诊</div>
				<div class="mui-input-row mui-radio mui-left">
			  		<label>否</label>
					<input name="otherInfo[zhuanzhen]" type="radio" value="1">
				</div>
				<div class="mui-input-row mui-radio mui-left">
			  		<label>是</label>
					<input name="otherInfo[zhuanzhen]" type="radio"  value="2">
				</div>
			</div>
			<div class="treatment-list">
				<div class="mui-input-row">
					<label>转诊原因</label>
					<input type="text" placeholder="请输入原因" class="textR"  name="otherInfo[yuanyin]" disabled="true">
				</div>
				<div class="mui-input-row">
					<label>转诊至机构及科室</label>
					<input type="text" placeholder="请输入医院名称" class="textR"  name="otherInfo[keshi]" disabled="true">
				</div>
			</div>
		</div>
		<div  class="mui-input-group font3 MedicineBox">
			<div class="mui-table-view-cell">
				用药情况
				<div class="mui-pull-right"><font id="addMedicine" data-id="0">添加用药</font><font id="deleteMedicine">删除用药</font></div>
			</div>
		</div>
		<div  class="mui-input-group font3 MedicineUse">
			<div class="mui-table-view-cell">
				用药指导
				<div class="mui-pull-right"><font id="addMedicineUse" data-id="0">添加用药</font><font id="deleteMedicineUse">删除用药</font></div>
			</div>
		</div>
		<div  class="mui-input-group font3">
			<div class="mui-row Multiselect">
				<div class="mui-col-xs-12">康复措施</div>
				<div class="mui-input-row mui-checkbox mui-left">
			  		<label>生活劳动能力</label>
					<input name="recuperateMethod[sh]" type="checkbox" value="1" data-type="kfmqzz">
				</div>
				<div class="mui-input-row mui-checkbox mui-left">
			  		<label>职业训练</label>
					<input name="recuperateMethod[xl]" type="checkbox" value="2" data-type="kfmqzz">
				</div>
				<div class="mui-input-row mui-checkbox mui-left">
			  		<label>学习能力</label>
					<input name="recuperateMethod[xx]" type="checkbox" value="3" data-type="kfmqzz">
				</div>
				<div class="mui-input-row mui-checkbox mui-left">
			  		<label>社会交往</label>
					<input name="recuperateMethod[sj]" type="checkbox" value="4" data-type="kfmqzz">
				</div>
				<div class="mui-input-row mui-checkbox mui-left">
			  		<label>其他(请填写详情)</label>
					<input name="recuperateMethod[qt]" type="checkbox" value="5" data-type="kfmqzz">
				</div>
			</div>
			<div class="mui-input-row writeRemarks writeRemarks3">
				<input type="text" placeholder="请填写详情" name="recuperateMethod[Detail]" value="" disabled="true">
			</div>
		</div>
		<div  class="mui-input-group font3">
			<input type="hidden"  name="nextClassify"  value="" />
			<div class="mui-table-view-cell">
				<div class="mui-navigate-right">
					本次随访分类
					<span class="mui-pull-right" id="ThisFollowUp">请选择</span>
				</div>
			</div>
			<input type="hidden"  name="nextDate"  value="" />
			<div class="mui-table-view-cell">
				<div class="mui-navigate-right">
					下次访问时间
					<span class="mui-pull-right" id="nextTime">请选择</span>
				</div>
			</div>
		</div>
	</form>
	<div class="submitBottom">
		<button id="nextBtn">确定</button>
	</div>
</body>
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